July 2004

Dear Readers: Here's the Article for this Month:

Name of article:

Cancer Patient Compliance in the Self-Administration of a Pain Assessment Tool

Author(s): Caraceni A, Galbiati A, Brunelli C, Gorni G, Martini C, Zecca E, De Conno F.

Abstract: J Pain Symptom Management 2004; 27:417-424

Pain intensity is considered to be the main clinical variable that permits both the physician and the nurse to personalize and adjust the management of cancer pain. The selection of a pain measurement scale should be made from those proven to be psychometrically valid and practically feasible. The scales having these characteristics are: Visual Analogue Scale (VAS), Numerical Rating Scales (NRS) and Verbal Rating Scales (VRS).

The aim of this study was to evaluate the compliance of hospitalized patients with chronic cancer pain. Patients were referred to a palliative care consultation team. A self-administered pain form was used daily in which the patient described the intensity of his/her average pain when at rest and during movement three times a day: morning (from wakening until noon), afternoon (from 12 to 6 pm); evening (after 6 p.m.). The assessment tool used was a 0-10 NRS (0 = no pain, 10 = worst imaginable pain).

Pain assessment forms were distributed daily for 5 days per week (on Friday 2 forms were given for the weekend) during a 5-month study period. The forms were given to patients, described and explained during the first visit.

The daily compliance was classified by the number of pain scores on the forms completed by the patients: 1. completely filled in, 2. partially filled in, 3. not filled in at all. The compliance over time was defined as the number of assessment forms completed over the number of evaluation days available for each patient. When the forms were not complete, the patients were investigated for the reasons of non-compliance by means a structured interview.

During the five month study period, 106 patients participated and were followed for a median period of 10.6 days (range 1-32 days).

As far as compliance is concerned, it was observed that on average the patients had entirely filled in the form during 58% of the follow-up period, no part was filled in during 37% of the follow-up and only a part was partially filled in during 5% of the follow-up; 13.2% of the patients returned blank forms every day, whereas 23.5% of patients had completed the form for the 100% of the follow-up period.

Compliance was lower as the number of follow-up days increased (Pearson’s correlation coefficient 0.26, p<0.01). The subjective sensation of physical distress (26%), subjective psychological variables (44%) and the absence of pain (16%) were the most frequent reasons for non-compliance.

Why I chose this article

Whilst it is important to evaluate pain and use validated assessment tools, is not agreed upon as to which pain assessment tools should be used in clinical practice as well as in research. For instance, if we look at two studies, carried out in an outpatient setting, we find that in one a pain diary was used that required two daily pain self-assessments on a scale of 0 to 10 for two months (de Wit R et al. Pain 1999), and the other used two daily pain scores using a 5-level verbal categorical scale for 1 month (Maunsell E. et al. Cancer 2000). Both of these studies resulted in a much higher compliance rate compared with the study presented here that required 6 daily scores.

A similar low compliance was noted by Twycross et al. (JPSM 1996) who used a weekly distribution of the Brief Pain Inventory to hospice inpatients.

Apart from agreeing with the authors’ conclusions, I also believe that in addition to the necessity to educate and stimulate patients further regarding the importance of evaluating their pain, it is also necessary to use simple evaluation instruments distributed directly by the physicians and/or nurses who communicate directly with the patient. Obtaining information about the intensity of pain permits us to understand “THE PAIN” experienced by each patient.

It is through the communication of the intensity of the pain, that we can more fully understand “THE PAIN” of each patient.

Regards,

Carla Ripamonti, MD
Member of the Board of Directors, IAHPC